Reducing inappropriate delivery of therapy for suspected non-lethal arrhythmias

ABSTRACT

An implantable medical device (IMD) identifies suspected non-lethal ventricular arrhythmia, and takes one or more actions in response to the identification to avoid or delay delivery of a defibrillation or cardioversion shock. The IMD employs number of intervals to detect (NID) thresholds for detection of ventricular arrhythmias. When a NID threshold is met, the IMD determines whether the ventricular rhythm is a suspected non-lethal rhythm despite satisfying a NID threshold. In some embodiments, the IMD increases the NID threshold, i.e., extends the time for detection, in response to identifying a rhythm as a suspected non-lethal rhythm, and monitors subsequent ventricular beats to determine if the increased NID threshold is met before detecting a ventricular arrhythmia and delivering therapy. The IMD can determine whether a rhythm is a suspected non-lethal arrhythmia by, for example, comparing the median ventricular cycle length (VCL) to the median atrial cycle length (ACL).

TECHNICAL FIELD

The invention relates to cardiac pacing, and more particularly, todetection and treatment of ventricular arrhythmias.

BACKGROUND

Implantable medical devices (IMDs), such as implantable pacemakers,utilize a variety of techniques and/or algorithms to detect heartarrhythmias. Ventricular arrhythmias, such as ventricular fibrillation(VF) and ventricular tachycardia (VT), are particularly dangerous, andcan result in death if not quickly terminated by delivery of a therapy.Consequently, IMDs are programmed to deliver therapy, such asdefibrillation or cardioversion shocks, upon detecting VF or VT.

IMDs typically detect VF and VT by measuring the intervals betweenventricular depolarizations, i.e., ventricular cycle lengths (VCLs), anddetermining whether recently measured VCLs are indicative of VF or VT.However, supraventricular tachycardias (SVTs), such as sinustachycardia, atrial fibrillation, atrial flutter, and reentrant atrialtachycardia, can be conducted to the ventricles, and can lead to shortVCLs that falsely indicate VF or VT. Delivery of defibrillation orcardioversion shocks to the ventricles in situations where an SVT causesVF or VT to be falsely detected is generally not clinically needed andusually is ineffective in terminating the SVT. Moreover, defibrillationand cardioversion shocks, which can be delivered a number of timesduring an SVT episode that leads to false VF of VT detection, can causesignificant patient discomfort or induce a VF or VT.

In order to avoid false detection of VF or VT during SVT episodes, someIMDs apply further analysis the ventricular rhythm and additionallyanalyze the atrial rhythm to determine if an SVT is the cause of thefast ventricular rhythm, i.e., apply specific SVT detection rules. Ifthe criteria for VF or VT is met during a particular ventricularinterval and the further analysis indicates the presence of an SVT, anIMD typically avoids detection of VF or VT during that interval and, insome cases, delivers a therapy to one or more atria, such asanti-tachycardia pacing or a cardioversion shock. Nonetheless, becauseIMDs are programmed to err on the side of over-detecting potentiallylethal VF and VT, IMDs occasionally inappropriately detect VF or VT whenthe fast ventricular rhythm is non-lethal, e.g., caused by an SVT,despite such additional analysis.

In order to avoid inappropriate delivery of defibrillation andcardioversion shocks, and the substantial patient discomfort associatedtherewith, clinicians in some cases program IMDs to prevent delivery oftherapy for ventricular rhythms that are slower than a certain median ofmean cycle length. This makeshift solution is not without problems,however. Slow arrhythmias can cause patient symptoms, such as fatigue,dizziness, and fainting, and can quickly accelerate into a moredangerous arrhythmia. Further, such clinician programming generally doesnot eliminate all inappropriate detection of VF and VT.

SUMMARY

In general, the invention is directed to techniques for reducinginappropriate delivery of therapy to treat non-lethal ventriculararrhythmias, e.g., ventricular arrhythmias caused by a supraventriculartachycardia (SVT). An implantable medical device (IMD), such as apacemaker or pacemaker-cardiovertor-defibrillator (PCD), identifies asuspected non-lethal ventricular arrhythmia, and takes one or moreactions in response to the identification to avoid or delay delivery ofa defibrillation or cardioversion shock. By reducing inappropriatedelivery of therapy in this manner, the IMD can reduce the unnecessaryoccurrences of patient discomfort associated with delivery of suchtherapy.

The IMD employs number of intervals to detect (NID) thresholds fordetection of ventricular arrhythmias. When a NID is met, the IMDdetermines whether the ventricular rhythm is a suspected non-lethalrhythm despite satisfying the NID. In some embodiments, the IMDincreases the NID, i.e., extends the time for detection, in response toidentifying a rhythm as a suspected non-lethal rhythm, and monitorssubsequent ventricular beats to determine whether the increased NID ismet before detecting a ventricular arrhythmia and delivering therapy. Byincreasing the NID, the IMD allows more time for an SVT to terminate orthe ventricular cycle length to slow down, for evidence of the SVT tobecome apparent, or for a slow ventricular arrhythmia to spontaneouslyterminate or develop into a ventricular arrhythmia that warrantsdelivery of a therapeutic shock.

In some embodiments, the IMD additionally or alternatively changes thetherapy to be delivered in response to determining that a rhythm is asuspected non-lethal arrhythmia. For example, where a sequence ofdefibrillation or cardioversion shocks was scheduled to be delivered inresponse to detection of a ventricular fibrillation (VF) or ventriculartachycardia (VT), the IMD can reduce the number of shocks in thesequence and/or deliver anti-tachycardia pacing (ATP) instead of orprior to delivery of the defibrillation or cardioversion shocks. WhereATP was scheduled, the IMD can reduce or increase the number of ATPattempts. The changed therapy can be delivered upon the determinationthat the rhythm is suspected non-lethal, or, where NID-increasing isadditionally implemented, upon a determination that an increased NID hasbeen met.

The IMD can determine whether a rhythm is a suspected non-lethalarrhythmia in a number of ways. For example, in some embodiments, theIMD compares the median ventricular cycle length (VCL) to the medianatrial cycle length (ACL), and makes the determination based on thecomparison. A median VCL that is longer than the median ACL, or shorterthan the median ACL by less than a threshold value is indicative of thepresence of an SVT that may be causing the fast ventricular rhythm. Insome embodiments, mean ventricular and atrial cycle lengths are usedinstead of median ventricular and atrial cycle lengths.

In some embodiments, the IMD uses other indicators instead of or inaddition to a comparison of ventricular and atrial cycle lengths todetermine whether a rhythm is a suspected non-lethal arrhythmia. Forexample, the IMD can determine whether a rhythm is a suspectednon-lethal arrhythmia based on the regularity of ventricular cyclelengths and/or morphological features of the rhythm, A:V association,rate of onset within measured ACLs, VCLs, or A-V intervals, or somephysiological parameter of the patient such as an intracardiac pressure,respiration rate, respiration depth, or activity level. In someembodiments, the IMD employs a minimum median or mean VCL for suspectednon-lethal arrhythmias. In other words, arrhythmias less than athreshold median or mean VCL will be will be presumed to be dangerousand accordingly will be detected and treated.

In some embodiments, the IMD further determines whether a suspectednon-lethal arrhythmia is a slow suspected non-lethal arrhythmia bydetermining whether the median or mean VCL is greater than or equal to aslow suspected non-lethal threshold. In such embodiments, the IMD cantreat slow suspected non-lethal arrhythmias differently than othersuspected non-lethal arrhythmias because they are presumed to pose lessof a risk to the patient. In particular, the IMD can increase the NIDthreshold by a greater amount for slow suspected rhythms than othersuspected rhythms and/or provide a different therapy change for slowsuspected rhythms than other suspected rhythms. For example, where theIMD would reduce the number of defibrillation or cardioversion shocksand add ATP attempts for suspected non-lethal arrhythmias, the IMD caneliminate the shocks and instead deliver ATP alone for slow suspectednon-lethal arrhythmias. In some embodiments, the IMD can simply notdeliver any therapy upon detection of a slow suspected non-lethalarrhythmia.

In some embodiments, the IMD classifies relatively slow, monomorphic VTsas suspected non-lethal arrhythmias instead of or in addition toclassifying suspected SVTs as suspected non-lethal arrhythmias. Slowermonomorphic VTs are often terminable by ATP or spontaneously terminate,and consequently, like SVTs, do not pose as great a risk to the patientas less stable or faster VTs or VF. Monomorphic VTs are classified assuspected non-lethal arrhythmias based on the regularity of measured VCLand/or morphological features of the ventricular rhythm, as well as theabsolute value of the VCL. In such embodiments, the IMD can employ aminimum median or mean VCL for suspected non-lethal arrhythmias, and canfurther classify suspected non-lethal arrhythmias as slow suspectednon-lethal arrhythmias, as described above.

In some embodiments, the IMD additionally or alternatively determineswhether the NID threshold for a ventricular arrhythmia has been met inerror due to cardiac or non-cardiac oversensing. Cardiac oversensing canfor example be caused by T-wave oversensing, while non-cardiacoversensing is caused by noise within a detected cardiac signal, such asnoise caused by lead failure, a loose set screw, or the like. When theIMD identifies cardiac or non-cardiac oversensing, the IMD classifiesthe ventricular rhythm as a suspected non-lethal cardiac rhythm, and canincrease the NID threshold and/or modify a scheduled therapy asdescribed above. Cardiac and non-cardiac oversensing can result in veryshort measured VCLs, and the IMD can identify cardiac and non-cardiacoversensing by determining that a median or mean VCL is less than orequal to an oversensing threshold value.

In one embodiment, the invention is directed to a method in whichventricular cycle lengths within a ventricular rhythm are measured, andit is determined that a number of intervals to detect (NID) thresholdfor a ventricular arrhythmia is met based on the measured ventricularcycle lengths. It is further determined that the ventricular rhythm is asuspected non-lethal arrhythmia subsequent to the determination that theNID threshold is met, and the NID threshold is increased based on thedetermination that the rhythm is a suspected non-lethal arrhythmia.Subsequent ventricular cycle lengths are measured to determine whetherthe increased NID threshold is met.

In another embodiment, the invention is directed to a medical devicethat includes electrodes to detect depolarizations of ventricles of aheart, a memory to store a number of intervals to detect threshold for aventricular arrhythmia, and a processor. The processor measuresventricular cycle lengths within a ventricular rhythm based on detectedventricular depolarizations, determines that the NID threshold is metbased on the measured ventricular cycle lengths, determines that theventricular rhythm is a suspected non-lethal arrhythmia subsequent tothe determination that the NID is met, increases the NID based on thedetermination that the rhythm is a suspected non-lethal arrhythmia, andmeasures subsequent ventricular cycle lengths based on detectedventricular depolarizations to determine whether the increased NID ismet.

In another embodiment, the invention is directed to a medical devicecomprising means for detecting depolarizations of ventricles of a heart,means for measuring ventricular cycle lengths within a ventricularrhythm based on detected ventricular depolarizations, means fordetermining that the NID threshold is met based on the measuredventricular cycle lengths, means for determining that the ventricularrhythm is a suspected non-lethal arrhythmia subsequent to thedetermination that the NID is met, means for increasing the NID based onthe determination that the rhythm is a suspected non-lethal arrhythmia,and means for measuring subsequent ventricular cycle lengths based ondetected ventricular depolarizations to determine whether the increasedNID is met

In another embodiment, the invention is directed to a method in whichventricular cycle lengths within a ventricular rhythm are measured, andit is determined that a number of intervals to detect (NID) thresholdfor a ventricular arrhythmia is met based on the measured ventricularcycle lengths. It is further determined that the ventricular rhythm is asuspected non-lethal arrhythmia subsequent to the determination that theNID is met, and a therapy scheduled for the ventricular arrhythmia ischanged based on the determination the that ventricular rhythm is asuspected non-lethal arrhythmia.

The details of one or more embodiments of the invention are set forth inthe accompanying drawings and the description below. Other features,objects, and advantages of the invention will be apparent from thedescription and drawings, and from the claims.

BRIEF DESCRIPTION OF DRAWINGS

FIG. 1 is a conceptual diagram illustrating an example implanted medicaldevice that reduces inappropriate delivery of therapy for suspectednon-lethal arrhythmias implanted within a patient.

FIG. 2 is a conceptual diagram illustrating the implantable medicaldevice of FIG. 1 and the heart of the patient in greater detail.

FIG. 3 is a functional block diagram illustrating the implantablemedical device of FIG. 1 in greater detail.

FIG. 4 is a flow diagram illustrating an example technique employed bythe implantable medical device of FIG. 1 to reduce inappropriatedelivery of therapy for suspected non-lethal arrhythmias by increasing anumber of intervals to detect threshold.

FIG. 5 is a flow diagram illustrating an example technique employed bythe implantable medical device of FIG. 1 to reduce inappropriatedelivery of therapy for suspected non-lethal arrhythmias by changing aventricular therapy scheduled for the arrhythmia.

FIG. 6 is a flow diagram illustrating an example technique employed bythe implantable medical device of FIG. 1 to reduce inappropriatedelivery of therapy for suspected non-lethal arrhythmias by combiningthe techniques of FIGS. 4 and 5.

FIG. 7 is a flow diagram illustrating an example technique employed bythe implantable medical device of FIG. 1 to determine whether aventricular rhythm is a suspected non-lethal arrhythmia.

FIG. 8 is a flow diagram illustrating an example technique employed bythe implantable medical device of FIG. 1 to reduce inappropriatedelivery of therapy for suspected non-lethal arrhythmias that includesapplication of separate, specific SVT detection rules.

FIG. 9 is a flow diagram illustrating an example technique employed bythe implantable medical device of FIG. 1 to reduce inappropriatedelivery of therapy for suspected non-lethal arrhythmias that includesfurther classification of suspected non-lethal arrhythmias as slowsuspected non-lethal arrhythmias.

FIG. 10 is a flow diagram illustrating an example technique employed bythe implantable medical device of FIG. 1 to determine whether asuspected non-lethal arrhythmia is a slow suspected non-lethalarrhythmia.

DETAILED DESCRIPTION

FIG. 1 is a conceptual diagram illustrating an example implanted medicaldevice (IMD) 10 that reduces inappropriate delivery of therapy forsuspected non-lethal arrhythmias implanted within a patient 12. Inexemplary embodiments, IMD 10 takes the form of a multi-chamberpacemaker with cardioversion and/or defibrillation capability. In theexemplary embodiment illustrated in FIG. 1, IMD 10 is coupled to leads14A and 14B (collectively “leads 14”) that extend into the heart 16 ofpatient 12. More particularly, right ventricular (RV) lead 14A extendsthrough one or more veins (not shown), the superior vena cava, and rightatrium 18, and into right ventricle 20, and right atrial (RA) lead 14Aextends through the veins and superior vena cava, and into the rightatrium 18 of heart 16.

IMD 10 senses electrical signals attendant to the depolarization andrepolarization of heart 16 and provides pacing pulses via electrodes(not shown) located on leads 14. The electrodes located on leads 14 areunipolar or bipolar. In some embodiments, leads 14 include coildefibrillation electrodes, and IMD 10 also provides defibrillationand/or cardioversion shocks via the defibrillation electrodes.

IMD 10 detects ventricular arrhythmias via the electrodes located onleads 14. IMD 10 measures ventricular cycle lengths (VCLs) via theelectrodes located on leads 14, and detects ventricular arrhythmias,such as ventricular fibrillation (VF), ventricular tachycardia (VT) andfast VT (FVT), based on the measured VCLs. In exemplary embodiments, IMD10 specifies a VCL zone for each of the ventricular arrhythmia types,and determines whether measured VCLs fall into the specified zones.

IMD 10 detects a ventricular arrhythmia if a sufficient number of VCLsmeasured during a time period that precedes and includes the currentventricular interval fall within the VCL zone associated with thatarrhythmia. IMD 10 stores a number of intervals to detect (NID)threshold for each arrhythmia that identifies the required number ofVCLs for detection of an arrhythmia within each zone. The NID thresholdis conventionally referred to in shorthand form as “the NID.” The NIDcan be expressed, for example, as a number of intervals within the zonewithin a period of time, i.e., a “time to detect,” a number ofconsecutive intervals within the zone, or as a fraction, e.g., “A” ofthe last “B” intervals within the zone.

As will be described in greater detail below, when IMD 10 determinesthat a NID for a ventricular arrhythmia is met, IMD 10 furtherdetermines whether the ventricular rhythm in question is a suspectednon-lethal arrhythmia, e.g., a supraventricular tachycardia (SVT) orslower monomorphic VT. If the ventricular rhythm is a suspectednon-lethal arrhythmia, IMD 10 takes one or more actions to reduce thelikelihood of inappropriate delivery of therapy. In some embodiments,for example, IMD 10 increases the NID for the initially detectedarrhythmia, and measures subsequent VCLs to determine if the increasedNID is met. In some embodiments, IMD 10 changes a ventricular therapyscheduled for the initially detected arrhythmia. In some embodiments,IMD 10 both increases the NID and changes the therapy. In someembodiments, IMD 10 additionally provides an atrial therapy, such asatrial anti-tachycardia pacing (ATP) in response to the determinationthat the ventricular rhythm is a suspected non-lethal ventriculararrhythmia.

Changing a ventricular therapy can include canceling some or all of thescheduled therapies for the initially detected arrhythmia, e.g.,canceling defibrillation or cardioversion shocks or canceling bothshocks and scheduled anti-tachycardia pacing (ATP) attempts. Changing aventricular therapy can also include adding ATP attempts where none arescheduled, or increasing or decreasing the number of schedule ATPattempts. In some embodiments, changing a ventricular therapy includeschanging a shock energy level or pathway to increase the likelihood ofterminating an underlying SVT.

The configuration of IMD 10 and leads 14 illustrated in FIG. 1 is merelyexemplary. In various embodiments, IMD 10 is coupled any number of leads14 that extend to a variety of positions within or outside of heart 16.For example, in some embodiments, IMD 10 is coupled to a lead 14 thatextends to a position within coronary sinus and great vein 26 near leftventricle 24 for left ventricular sensing and/or pacing. In someembodiments, at least some of leads 14 are epicardial leads. Further, insome embodiments, IMD 10 is not implanted within patient 12, but isinstead coupled with percutaneous leads 14 that extend through the skinof patient 12 to a variety of positions within or outside of heart 16,or transcutaneous leads that detect electrical activity within the heartfrom positions on the surface, e.g., skin, of patient.

FIG. 2 is conceptual diagram further illustrating IMD 10 and heart 16 ofpatient 12. In exemplary embodiments, each of leads 14 includes anelongated insulative lead body carrying a number of concentric coiledconductors separated from one another by tubular insulative sheaths.Located adjacent distal end of leads 14A and 14B are bipolar electrodes30 and 32, and 34 and 36, respectively. In exemplary embodiments,electrodes 30 and 34 take the form of ring electrodes, and electrodes 32and 36 take the form of extendable helix tip electrodes mountedretractably within insulative electrode heads 38 and 40, respectively.Each of the electrodes 30-36 is coupled to one of the coiled conductorswithin the lead body of its associated lead 14.

Sense/pace electrodes 30-36 sense electrical signals attendant to thedepolarization and repolarization of heart 16. The electrical signalsare conducted to IMD 10 via leads 14. In exemplary embodiments, at leastsome of sense/pace electrodes 30-36 further deliver pacing to causedepolarization of cardiac tissue in the vicinity thereof. In someembodiments, IMD 10 also includes one or more indifferent housingelectrodes, such as housing electrode 46, formed integrally with anouter surface of the hermetically sealed housing 48 of IMD 10. In suchembodiments, any of electrodes 30-36 are capable of being used forunipolar sensing or pacing in combination with housing electrode 46.

As shown in FIG. 2, leads 14A and 14B also carry elongated coildefibrillation electrodes 42 and 44, respectively. In exemplaryembodiments, defibrillation electrodes 42 and 44 are fabricated fromplatinum, platinum alloy or other materials known to be usable inimplantable defibrillation electrodes, and may be about 5 cm in length.IMD 10 delivers cardioversion and/or defibrillation therapy to heart 16,and more particularly right ventricle 20 and left ventricle 22, via oneor more of elongated coil electrodes 42 and 44.

In some embodiments, IMD 10 also includes a sensor 50 that generates asignal as a function of a physiological parameter of patient 12. In suchembodiments, IMD 10 processes the output of sensor 50 to determinewhether a ventricular rhythm initially detected as a ventriculararrhythmia is a suspected non-lethal ventricular arrhythmia. Inexemplary embodiments, sensor 50 takes the form of an intracardiacpressure sensor such as a capacitive absolute pressure sensor, asdescribed in U.S. Pat. No. 5,564,434 to Halperin, et al., herebyincorporated by reference herein in its entirety, a piezoelectriccrystal, or piezoresistive pressure transducer.

FIG. 3 is a functional block diagram of IMD 10. In the illustratedembodiment, IMD 10 takes the form of a multi-chamber pacemaker withcardioversion and/or defibrillation capability having amicroprocessor-based architecture. However, this diagram should be takenas exemplary of the type of device in which various embodiments of thepresent invention may be embodied, and not as limiting. For example,some embodiments of the invention provide no defibrillation orcardioversion therapy, but instead are pacemakers that provideanti-tachycardia pacing (ATP) to treat detected arrhythmias.

IMD 10 includes a microprocessor 60. Microprocessor 60 executes programinstructions stored in memory, such as a ROM (not shown), EEPROM (notshown), and/or RAM 62, which control microprocessor 60 to perform thefunctions ascribed to microprocessor 60 herein. Microprocessor 60 iscoupled to, e.g., communicates with and/or controls, various othercomponents of IMD 10 via an address/data bus 64.

Electrodes 30 and 32 are coupled to amplifier 66, which takes the formof an automatic gain controlled amplifier providing an adjustablesensing threshold as a function of the measured R-wave amplitude. Asignal is generated on RV out line 68 whenever the signal sensed betweenelectrodes 30 and 32 exceeds the present sensing threshold. Electrodes34 and 36 are coupled to amplifier 70, which also takes the form of anautomatic gain controlled amplifier providing an adjustable sensingthreshold as a function of measured P-wave amplitude. A signal isgenerated on RA out line 72 whenever the signal sensed betweenelectrodes 34 and 36 exceeds the present sensing threshold.

IMD 10 paces heart 16. Pacer timing/control circuitry 74 includesprogrammable digital counters which control the basic time intervalsassociated with modes of pacing. Pacer timing/control circuitry 74 alsocontrols escape intervals associated with pacing. In the exemplarytwo-chamber pacing environment, pacer timing/control circuitry 74controls the atrial and ventricular escape intervals that are used totime pacing pulses delivered to right atrium 18 and right ventricle 20.

Intervals defined by pacer timing/control circuitry 74 also include therefractory periods during which sensed R-waves and P-waves areineffective to restart timing of the escape intervals, and the pulsewidths of the pacing pulses. The durations of these intervals aredetermined by microprocessor 60 in response to data stored in RAM 62,and are communicated to circuitry 74 via address/data bus 64. Pacertiming/control circuitry 74 also determines the amplitude of the cardiacpacing pulses under control of microprocessor 60.

During pacing, escape interval counters within pacer timing/controlcircuitry 74 are reset upon sensing of R-waves and P-waves as indicatedby signals on lines 68 and 72, and, in accordance with the selected modeof pacing, circuitry 74 controls generation and delivery of pacingpulses upon time-out of the escape intervals. Circuitry 74 also resetsescape interval counters upon generation of pacing pulses. Circuitry 74uses the value of the count present in escape interval counters whenreset by sensed R-waves and P-waves, or delivered pacing pulses, tomeasure ventricular cycle lengths (VCLs) and, in some embodiments,atrial cycle lengths (ACLs). Circuitry 74 provides the measured VCL andACL values to microprocessor 60 for detection of arrhythmias, which willbe described in greater detail below, via address/data bus 64.

Microprocessor 60 operates as an interrupt driven device, and isresponsive to interrupts from pacer timing/control circuitry 74corresponding to the occurrence of sensed P-waves and R-waves andcorresponding to the generation of cardiac pacing pulses. Thoseinterrupts are provided via data/address bus 64. Any necessarymathematical calculations to be performed by microprocessor 60 and anyupdating of the values or intervals controlled by pacer timing/controlcircuitry 74 take place following such interrupts.

In accordance with the selected mode of pacing, pacer timing/controlcircuitry 74 triggers generation of pacing pulses by one or more ofpacer output circuits 76 and 78, which are coupled to electrodes 30 and32, and 34 and 36, respectively. Output circuits 76 and 78 are pulsegeneration circuits, which include capacitors and switches for thestorage and delivery of energy as a pulse.

In some embodiments, IMD 10 detects ventricular arrhythmias usingtachycardia and fibrillation detection techniques and algorithmsdescribed above with reference to FIG. 1. For example, RAM 62 can storeNID thresholds for various ventricular arrhythmias, and microprocessor60 can detect ventricular arrhythmias by receiving VCLs from pacertiming/control circuitry 74, categorizing the VCLs based on VCL rangesfor the various types of arrhythmias, and counting VCLs within eachcategory. A clinician can program values for the VCL ranges and NIDs viaa programming device and device telemetry, as is well known in the art.NIDs stored by RAM 62 can include a VF NID, VT NID, FVT NID, and acombined count NID in which intervals classified as VF or VT areconsidered together.

In response to detection of an arrhythmia, IMD 10 is capable ofdelivering one or more anti-tachycardia pacing (ATP) therapies to heart16, and/or defibrillation or cardioversion shocks to heart 16 via one ormore of electrodes 30-36 and 42-46. Electrodes 42 and 44 are coupled todefibrillation circuit 80, which delivers defibrillation and/orcardioversion pulses under the control of microprocessor 60.Defibrillation circuit 80 includes energy storage circuits such ascapacitors, switches for coupling the storage circuits to coilelectrodes 42 and 44, and logic for controlling the coupling of thestorage circuits to the electrodes to create pulses with desiredpolarities and shapes. Microprocessor 60 may employ an escape intervalcounter to control timing of such defibrillation pulses, as well asassociated refractory periods.

A clinician can program therapies or sequences of therapies for each ofthe types of ventricular arrhythmias via a programming device and devicetelemetry, and information describing the programmed therapies and/orsequences of therapies can be stored in RAM 62. The programmed therapiescan include sequences of one or more defibrillation pulses, one or morecardioversion pulses, one or more ATP attempts, or combinations thereof.

As described above, when microprocessor 60 determines that a NID for aventricular arrhythmia is met based on measured VCLs, microprocessor 60further determines whether the ventricular rhythm is a suspectednon-lethal arrhythmia, e.g., an SVT, monomorphic VT, or a rhythm causesby cardiac or non-cardiac oversensing. In some embodiments, for example,microprocessor 60 determines the median or mean VCL and ACL, e.g., overthe last 4-20 beats, and compares the values to determine if the rhythmis suspected non-lethal. In such embodiments, microprocessor 60determines that the rhythm is a suspected non-lethal arrhythmia whenmedian or mean ACL is substantially equal to or greater than the medianor mean VCL. When the ACL is substantially equal to or greater than theVCL, it is more likely that the fast ventricular rhythm is caused by anSVT. RAM 62 can store a suspect threshold value, and microprocessor 60can compare the difference or ratio between the VCL and ACL to thethreshold value to determine whether the rhythm is suspect.

In some embodiments, RAM 62 stores a minimum VCL threshold for suspectednon-lethal arrhythmias, e.g., 270 milliseconds. In such embodiments,microprocessor 60 compares the mean or median VCL to the minimum VCL,and only indicates that the rhythm is suspect if the VCL value exceedsthe threshold value. In other words, certain fast rhythms should betreated without delay and with an originally scheduled therapy despiteother analysis indicating that the rhythm is suspected non-lethal.

In other embodiments, microprocessor 60 additionally or alternativelyanalyzes the regularity of measured VCLs and/or morphological featuresthe ventricular rhythm to determine whether the arrhythmia is suspectednon-lethal. Microprocessor 60 can, for example, calculate thevariability of measured VCLs over the previous 10 intervals, and themorphological analysis can include, for example, an analysis of thewidth of ventricular depolarizations and/or a wavelet analysis.

In some embodiments, microprocessor 60 additionally or alternativelyanalyzes the level of association between the occurrence of atrial andventricular depolarizations, e.g., the level of A:V association, and/orthe rate of onset within measured ACLs, VCLs, and/or A-V intervals todetermine whether the arrhythmia is suspected non-lethal. A relativelyhigh level of A:V association, or a relatively slow rate of onset ofmeasures ACLs, VCLs, and/or A-V intervals can indicate the presence ofan SVT such as sinus tachycardia.

In exemplary embodiments, a ventricular electrogram (EGM) signalreceived via a combination of any of electrodes 30, 32 and 46 isdigitally processed by a digital signal processor (DSP) 82 formorphological analysis of the signal. In such embodiments, switch matrix84 is used to select which of electrodes 30, 32 and 46 are coupled towide band (0.5-200 Hz) amplifier 86 for use in digital signal analysis.Selection of electrodes is controlled by microprocessor 60 viadata/address bus 66, and the selections may be varied as desired. TheEGM signal is converted to a digital signal by analog to digitalconverter circuit 88, and provided to DSP 82 via address/data bus 66. Insome embodiments, the digital signal is stored in RAM 62, and retrievedthere from by DSP 82 for analysis. In other embodiments, IMD 10 does notinclude a dedicated DSP 82, and microprocessor 60 performs the digitalsignal analysis described herein.

Substantial irregularity of measured VCLs and/or ventricular electrogrammorphology can be caused by an SVT. However, substantial regularity ofmeasured VCLs and/or ventricular electrogram morphology can indicate amonomorphic VT. In both cases, the regularity of measured VCLs and/orthe electrogram morphology is used to detect or confirm that aventricular arrhythmia is a suspected non-lethal arrhythmia.

IMD 10 is shown in FIG. 3 as including an activity sensor 94. In someembodiments, microprocessor 60 additionally or alternatively determineswhether a rhythm is a suspected non-lethal arrhythmia based on theactivity level of patient 12. For example, and high activity level canindicate that the fast ventricular rhythm is a sinus tachycardia causedby patient 12 exercising, and therefore a suspected non-lethalarrhythmia.

Activity sensor 94 typically (although not necessarily) provides asensor output that varies as a function of a measured parameter relatingto metabolic requirements of patient 12. In exemplary embodiments,activity sensor 94 is a piezoceramic accelerometer bonded to a hybridcircuit located inside housing 48 (FIG. 2). In other embodiments,activity sensor 94 additionally or alternatively comprises electrodes todetect respiration rate of patient 12 via cyclical variations in thethoracic impedance of patient 12. The output signal provided by activitysensor 94 is coupled to an activity detection circuit 96, whichdetermines the activity level, e.g., counts, of patient 12 based on theoutput. The activity level or counts are provided to microprocessor 60,which determines whether a ventricular rhythm that meets an initial NIDfor an arrhythmia is in fact a suspected non-lethal based on theactivity level.

In the illustrated example, IMD 10 also includes a parameter monitorcircuit 98. Parameter monitor circuit 98 processes the signal receivedfrom sensor 50, and provides a result of the processing tomicroprocessor 60 for use in determining whether a fast ventricularrhythm is a suspected non-lethal arrhythmia. In exemplary embodimentswhere sensor 50 is an intracardiac pressure sensor, monitor circuit 94processes the pressure signal to provide information indicatingintracardiac pressure values to microprocessor 60. Microprocessor 60can, for example, analyze the pressure values to determine whether theintracardiac pressure is stable. A stable pressure can indicate that therhythm is suspected non-lethal, while an unstable pressure can indicatethat treatment of the rhythm should not be delayed or altered.Intracardiac pressures often remain stable during, SVTs, slowermonomorphic VTs, and when an arrhythmia is incorrectly identified due tocardiac or non-cardiac oversensing.

In response to determining that a rhythm that meets the NID for anarrhythmia is a suspected non-lethal arrhythmia, microprocessor 60 cantake a variety of actions to delay delivery of or change a therapyscheduled for delivery in response to detection of that arrhythmia. Forexample, microprocessor 60 can increase the NID and monitor subsequentVCLs to determine if the rhythm meets the increased NID. As anotherexample, microprocessor can change the ventricular therapy scheduled forthe initially detected arrhythmia.

In some embodiments, the microprocessor 60 further determines whether asuspected non-lethal arrhythmia is a slow suspected non-lethalarrhythmia. In such embodiments, microprocessor 60 by determiningwhether the median or mean VCL is greater than a slow suspectednon-lethal threshold value, e.g., 370 milliseconds. RAM 62 stores theslow suspected non-lethal threshold value.

In such embodiments, microprocessor 60 can treat slow suspectednon-lethal arrhythmias differently than other suspected non-lethalarrhythmias because they are presumed to pose even less of a risk to thepatient than other suspected non-lethal arrhythmias. In particular,microprocessor 60 can increase the NID threshold by a greater amount forslow suspected rhythms than other suspected rhythms and/or provide adifferent therapy change for slow suspected rhythms than other suspectedrhythms. For example, where the microprocessor 60 would reduce thenumber of defibrillation or cardioversion shocks and add ATP attemptsfor suspected non-lethal arrhythmias, microprocessor 60 can eliminatethe shocks and instead deliver ATP alone for if the suspected non-lethalarrhythmia is a slow suspected non-lethal arrhythmias. In someembodiments, the microprocessor 60 can simply withhold delivery of anytherapies based on the determination that the rhythm is a slow suspectednon-lethal arrhythmia, i.e., can extend the NID and detect based on theextended NID without delivery of therapy upon detection, or can simplyreset the NID upon a determination that the rhythm is a slow suspectednon-lethal arrhythmia.

Although IMD 10 is described herein as having separate processors,microprocessor 60 may perform both the functions ascribed to it hereinand digital signal analysis functions ascribed to DSP 82 herein.Moreover, although described herein in the context ofmicroprocessor-based pacemaker embodiment IMD 10, the invention may beembodied in various implantable medical devices that include one or moreprocessors, which may be microprocessors, DSPs, FPGAs, or other digitallogic circuits.

FIG. 4 is a flow diagram illustrating an example technique employed byIMD 10 to reduce inappropriate delivery of therapy for suspectednon-lethal arrhythmias by increasing a NID threshold. Microprocessor 60measures VCLs within a ventricular rhythm (100), and determines whethera NID for an arrhythmia is met (102). When the NID for a ventriculararrhythmia is met, microprocessor 60 further determines whether therhythm is a suspected non-lethal arrhythmia using any of the techniquesdescribed above (104).

If microprocessor 60 determines that the rhythm is not suspect,microprocessor 60 controls delivery of therapy (114) by, for example,controlling delivery of a defibrillation shock via defibrillationcircuit 80. However, if microprocessor 60 determines that the rhythm isa suspected non-lethal arrhythmia, microprocessor 60 increases the NID(106), and measures subsequent VCLs (108) to determine whether theincreased NID is met (110). In some embodiments, microprocessor 60compares a median or mean VCL to a median or mean ACL, and determineswhether the rhythm is suspect based on the comparison. In someembodiments, a clinician programs the initial NID and the amount ofincrease for the NID. In other embodiments, microprocessor 60 adaptivelydetermines the amount of increase for the NID based on the VCL/ACLcomparison, e.g., the difference between the VCL and ACL, the median ormean VCL itself, and/or a measured value of a physiological parametersuch as an intracardiac pressure. RAM 62 can store information for thedetermination of NID increase, such as a function or look-up table.

Increasing the NID can include increasing an amount of time, a number ofintervals, or both. Because combined count NIDs include a number of“look-back” beats, i.e., a number of previous intervals to review todetermine whether a an arrhythmia detected via the combined count is afibrillation or tachycardia, Increasing a combined count NID can alsoinclude increasing a number of look-back beats. If the increased NID ismet (110), microprocessor 60 can control delivery of a ventriculartherapy scheduled for the detected arrhythmia (114). However, if theincreased NID is not met, microprocessor 60 can reset the NID for theinitially detected arrhythmia to its original value (112).

In some embodiments, when the increased NID is met microprocessor 60again determines whether the rhythm is a suspected non-lethalarrhythmia, and can further increase the NID. The second and subsequentincreases to the NID can be of a different amount than each other andfirst NID increase, e.g., the amount of the increases to the NID caniteratively increase or decrease.

FIG. 5 is a flow diagram illustrating an example technique employed byIMD 10 to reduce inappropriate delivery of therapy for suspectednon-lethal arrhythmias by changing a ventricular therapy scheduled forthe arrhythmia. Microprocessor 60 measures VCLs within a ventricularrhythm (120), and determines whether a NID for an arrhythmia is met(122). When the NID for a ventricular arrhythmia is met, microprocessor60 further determines whether the rhythm is a suspected non-lethalarrhythmia using any of the techniques described above (124).

If microprocessor 60 determines that the rhythm is not suspect,microprocessor 60 controls delivery of the primary therapy scheduled forthat arrhythmia (126). However, if microprocessor 60 determines that therhythm is a suspected non-lethal arrhythmia, microprocessor 60 changesthe ventricular therapy scheduled for that arrhythmia to a secondaryventricular therapy, and controls delivery of the secondary ventriculartherapy (128). A clinician can program the primary and secondarytherapies.

For example, where a sequence of one or more defibrillation ofcardioversion shocks was scheduled as the primary therapy to bedelivered in response to detection of a VF or VT, the secondary therapycan include a reduced number of shocks in the sequence or can replacesome or all of the shocks with one or more anti-tachycardia pacing (ATP)attempts for ventricles 20 and 22. Where delivery of ATP attempts toventricles 20 and 22 was scheduled as the primary therapy, the secondarytherapy can include a reduced or increased number of ATP attempts. Insome embodiments, the secondary therapy includes a therapy sequence thatis similar to the primary therapy but with different parameters, e.g.,different shock energy levels or pathways, or different ATP ramp ratesthan the primary therapy.

In some embodiments, microprocessor 60 additionally controls delivery oftherapy, such as ATP, to atria 18 and 24 upon a determination that aventricular rhythm is a suspected non-lethal arrhythmia. Delivery ofatrial therapy may terminate an underlying SVT where an SVT is suspectedas the cause of the detected fast ventricular rhythm.

FIG. 6 is a flow diagram illustrating an example technique employed byIMD 10 to reduce inappropriate delivery of therapy for suspectednon-lethal arrhythmias by combining the techniques of FIGS. 4 and 5.Microprocessor 60 measures VCLs within a ventricular rhythm (130), anddetermines whether a NID for an arrhythmia is met (132). When the NIDfor a ventricular arrhythmia is met, microprocessor 60 furtherdetermines whether the rhythm is a suspected non-lethal arrhythmia usingany of the techniques described above (134).

If microprocessor 60 determines that the rhythm is not suspect,microprocessor 60 controls delivery of therapy scheduled for thedetected arrhythmia (146). However, if microprocessor 60 determines thatthe rhythm is a suspected non-lethal arrhythmia, microprocessor 60changes the scheduled therapy as described above (136), and increasesthe NID (138). Microprocessor 60 then measures subsequent VCLs (140) todetermine whether the increased NID is met (142). If the increased NIDis met, microprocessor controls delivery of the scheduled therapy of thearrhythmia as changed (146). However, if the increased NID is not met,microprocessor 60 resets the NID and the scheduled therapy to theirinitial values (144).

In some embodiments, microprocessor 60 additionally controls delivery oftherapy, such as ATP, to atria 18 and 24 upon a determination that aventricular rhythm is a suspected non-lethal arrhythmia. Where the fastventricular rhythm is caused by an SVT, delivery of atrial therapy mayterminate the underlying SVT during the period in which the NID isextended, preventing inappropriate delivery of therapy at the end of theextended NID. Further, increasing the NID with or without delivery ofatrial therapy allows time for the initially detected arrhythmia,whether it is an SVT or monomorphic VT, to spontaneously terminatewithout delivery of ventricular shocks and the attendant patientdiscomfort. Changing the originally scheduled therapy, e.g., from shocksto ATP, can also reduce patient discomfort by avoiding delivery ofshocks, both in embodiments where the NID is increased (FIG. 6) and inembodiments where the changed therapy is delivered immediately upon adetermination that the rhythm is a suspected non-lethal arrhythmia (FIG.5).

FIG. 7 is a flow diagram illustrating an example technique employed byIMD 10 to determine whether a ventricular rhythm is a suspectednon-lethal arrhythmia. In particular, FIG. 7 illustrates an exampletechnique employed by IMD 10 to determine whether a ventricular rhythmis a suspected SVT. IMD 10 determines the median VCL and ACL for anumber of previous intervals, e.g., the ten intervals, that preceded theinterval in which a NID for an arrhythmia is met (150). If the medianVCL is greater than or equal to a minimum VCL threshold (“X”) forsuspected non-lethal arrhythmias, and the difference between the medianVCL and median ACL is greater than or equal to a suspect threshold (“Y”)(152), microprocessor 60 determines that the rhythm in question is asuspected non-lethal arrhythmia (154). If either of the thresholds isnot met, microprocessor 60 determines that the rhythm is non-suspect,and proceeds to deliver a ventricular therapy scheduled for the detectedarrhythmia (156).

RAM 62 stores the threshold values. In exemplary embodiments, theminimum VCL threshold (“X”) is approximately 270 milliseconds, while thesuspect threshold (“Y”) is equal to −30 milliseconds. In someembodiments, the suspect threshold is set at a small negative value sothat ventricular rhythms with a median VCL that is approximately equalto or greater than the median ACL are identified as suspect. Althoughatrial fibrillation and atrial flutter generally results in a median VCLthat is significantly greater than the median ACL, other SVTs such assinus tachycardia and atrial tachycardia can result in a median VCL thatis slightly less than the median ACL. In some embodiments,microprocessor 60 uses a mean VCL and mean ACL instead of the medianvalues.

Instead of or in addition to determining that a ventricular arrhythmiais a suspected SVT, in some embodiments IMD 10 determines whether therhythm is a suspected non-lethal arrhythmia by determining whether therhythm is a monomorphic VT. In such embodiments, microprocessor 60analyzes the regularity of the VCL lengths and/or the regularity of themorphological features of the rhythm, as described above, instead of orin addition to comparing median VCLs to median ACLs. In suchembodiments, microprocessor 60 can also apply a minimum VCL thresholdstored by RAM 62 so that fast and potentially dangerous arrhythmias aretreated upon satisfaction of the initial NID with the scheduled therapy.A monomorphic VT minimum VCL threshold can be the same as an SVT minimumVCL threshold, e.g., 270 milliseconds, or can be slightly longer, e.g.,300 milliseconds, because fast monomorphic VTs can pose greater risk topatient 12 then a ventricular rhythm of with the same median VCL causedby an SVT.

In some embodiments, IMD 10 additionally or alternatively determineswhether the NID threshold for a ventricular arrhythmia has been met inerror due to cardiac or non-cardiac oversensing. Cardiac oversensing canfor example be caused by T-wave oversensing, while non-cardiacoversensing is caused by noise within a detected cardiac signal, such asnoise caused by lead failure, a loose set screw, or the like. Whenmicroprocessor 60 identifies cardiac or non-cardiac oversensing,microprocessor 60 classifies the ventricular rhythm as a suspectednon-lethal cardiac rhythm.

Cardiac and non-cardiac oversensing can result in very short measuredVCLs, and microprocessor 60 can identify cardiac and non-cardiacoversensing by determining that a median or mean VCL is less than orequal to an oversensing threshold value. RAM 62 stores the oversensingthreshold value, which in exemplary embodiments is approximately 180milliseconds. In some embodiments, microprocessor 60 identifies cardiacor non-cardiac oversensing by applying techniques described incommonly-assigned U.S. patent application Ser. No. 10/135,080 byGunderson et al., filed Apr. 29, 2002.

In response to identifying cardiac or non-cardiac oversensing,microprocessor 60 can increase the NID threshold and/or modify ascheduled therapy as described above. The amount the microprocessor 60increases the NID threshold and/or the change to the therapy applied bymicroprocessor 60 upon identification of cardiac or non-cardiac sensingcan be the same as or different than the increases and/or changesapplied when a potential SVT or monomorphic VT is detected as asuspected non-lethal arrhythmia. In exemplary embodiments, themicroprocessor 60 applies a greater amount of NID threshold increasewhen a oversensing is suspected than when SVT or monomorphic VT issuspected. For example, where oversensing is suspected, microprocessorcan increase the NID threshold by to three to five times its originalvalue.

FIG. 8 is a flow diagram illustrating an example technique employed byIMD 10 to reduce inappropriate delivery of therapy for suspectednon-lethal arrhythmias that includes application of separate, specificSVT detection rules. In some embodiments IMD 10, and more particularlymicroprocessor 60, applies specific SVT detection rules to determine ifan SVT is the cause of the fast ventricular rhythm. For example, if aNID is met during a particular ventricular interval and the furtheranalysis indicates the presence of a confirmed SVT, IMD 10 can avoiddetection of VF or VT during that interval and wait to analyze the nextventricular interval and determine the unchanged NID continues to bemet.

However, as described above, such specific SVT rules often fail tocorrectly identify SVTs despite such additional analysis, andconsequently too often allow inappropriate delivery of therapy to occur.Such SVT detection rules fail to detect SVTs because they are designedto favor prompt delivery or therapy and result in no false positive SVTdetections. SVT detection rules can include analysis of A-V and V-Ainterval patterns, comparison of ACLs and VCLs, detection of A:Vdissociation, analysis of VCL regularity. An exemplary set of specificSVT detection rules is provided by pacemakers manufactured by Medtronic,Inc. and identified by the trade name PR-Logic™.

FIG. 8 illustrates an example technique wherein microprocessor 60determines whether a ventricular rhythm is a suspected non-lethalarrhythmia subsequent to application of specific SVT detection rules,allowing IMD 10 to avoid delivery of therapy in cases where the SVTdetection rules would fail to positively identify an SVT. Microprocessor60 measures VCLs within a ventricular rhythm (160), and determineswhether a NID for an arrhythmia is met (162). When the NID for aventricular arrhythmia is met, microprocessor 60 applies the SVTdetection rules (164).

If the SVT detection rules are satisfied (166), microprocessor 60measures the next VCL and determines whether the unchanged NID for theventricular arrhythmia is still met (162). However, if the SVT detectionrules are not satisfied, microprocessor 60 further determines whetherthe rhythm is a suspected non-lethal arrhythmia using any of thetechniques described above (168). In some embodiments, microprocessor 60determines whether the rhythm is suspect prior to application of the SVTdetection rules rather than after failure of the SVT rules to detect anSVT. By applying the SVT rules and the suspect determination analysis inthis order, microprocessor 60 can avoid unnecessary application of suchcomputational intensive rules and, to the extent that the rhythm isdetermined to be suspect, allow more time for the rhythm tospontaneously terminate.

If microprocessor 60 determines that the rhythm is not suspect,microprocessor 60 controls delivery of a therapy scheduled for thedetected arrhythmia (178). However, if microprocessor 60 determines thatthe rhythm is a suspected non-lethal arrhythmia, microprocessor 60increases the NID threshold for the arrhythmia (170), and measuressubsequent VCLs (172) to determine whether the increased NID is met(174). If the increased NID is met, microprocessor 60 can controldelivery of a ventricular therapy scheduled for the detected arrhythmia(178). However, if the increased NID is not met, microprocessor 60 canreset the NID for the initially detected arrhythmia to its originalvalue (176).

FIG. 9 is a flow diagram illustrating an example technique employed byIMD 10 to reduce inappropriate delivery of therapy for suspectednon-lethal arrhythmias that includes further classification of suspectednon-lethal arrhythmias as slow suspected non-lethal arrhythmias. In suchembodiments, IMD 10 treats slow suspected non-lethal arrhythmiasdifferently than other suspected non-lethal arrhythmias because they arepresumed to pose less of a risk to the patient. As will be described ingreater detail below, IMD 10 determines whether a suspected non-lethalarrhythmia is a slow suspected non-lethal arrhythmia based on acomparison of a median or mean VCL to a slow suspected non-lethalarrhythmia threshold value. When IMD 10 combines this comparison with acomparison of the median or mean VCL to the minimum suspected non-lethalarrhythmia threshold and oversensing threshold described above, IMD 10creates four VCL zones for detected arrhythmias in which the arrhythmiascan be treated differently.

Microprocessor 60 measures VCLs within a ventricular rhythm (180), anddetermines whether a NID for an arrhythmia is met (182). When the NIDfor a ventricular arrhythmia is met, microprocessor 60 furtherdetermines whether the rhythm is a suspected non-lethal arrhythmia usingany of the techniques described above (184).

If microprocessor 60 determines that the rhythm is not suspect,microprocessor 60 controls delivery of a scheduled therapy for thedetected ventricular arrhythmia (202). However, if microprocessor 60determines that the rhythm is suspect, microprocessor 60 furtherdetermines whether the rhythm is a slow suspected non-lethal tachycardia(186). If microprocessor 60 determines that the rhythm is not a slowsuspected non-lethal arrhythmia, microprocessor 60 applies a firstchange to a scheduled therapy (188) and increases the NID threshold by afirst amount (190). If microprocessor 60 instead determines that therhythm is a slow suspected non-lethal arrhythmia, microprocessor 60applies a second change to a scheduled therapy (192) and increases theNID threshold by a second, e.g., greater, amount (194).

After microprocessor 60 increases the NID threshold by either the firstor second amount, microprocessor 60 measures subsequent VCLs (196) todetermine whether the increased NID threshold is met (198). If theincreased NID threshold is not met, microprocessor 60 resets the NIDthreshold and the scheduled therapy to their original values. However,if the increased NID threshold is met, microprocessor 60 controlsdelivery of the scheduled therapy as previously changed based on thedetermination of whether the suspected non-lethal arrhythmia was a slowsuspected non-lethal arrhythmia (202).

Microprocessor 60 can apply either a first or second change to thescheduled therapy based on the determination of whether the suspectednon-lethal arrhythmia is a slow suspected non-lethal arrhythmia in anumber of ways. For example, where microprocessor 60 would reduce thenumber of defibrillation or cardioversion shocks and add ATP attemptsfor suspected non-lethal arrhythmias, microprocessor 60 can eliminatethe shocks and instead control delivery of ATP alone for slow suspectednon-lethal arrhythmias. In some embodiments, microprocessor 60 cansimply cancel delivery of any therapy upon the determination that asuspected non-lethal arrhythmia is a slow suspected non-lethalarrhythmia. In such embodiments, microprocessor 60 can detect thearrhythmia when the increased NID threshold is met and not controldelivery of any therapy in response to the detection, or can simplyreset the NID threshold upon the determination that the suspectednon-lethal arrhythmia is a slow suspected non-lethal arrhythmia.

FIG. 10 is a flow diagram illustrating an example technique employed byIMD 10 to determine whether a suspected non-lethal arrhythmia is a slowsuspected non-lethal arrhythmia. In particular, FIG. 10 illustrates anexample technique employed by IMD 10 to determine whether a ventricularrhythm is a suspected SVT, and further determine whether the suspectedSVT is a slow SVT.

IMD 10 determines the median VCL and ACL for a number of previousintervals, e.g., the twelve intervals that preceded the interval inwhich a NID for an arrhythmia is met (210). If the median VCL is greaterthan or equal to a minimum VCL threshold (“X”) for suspected non-lethalarrhythmias, and the difference between the median VCL and median ACL isgreater than or equal to a suspect threshold (“Y”) (212), microprocessor60 further determines whether the median VCL is greater than or equal toa slow suspected non-lethal arrhythmia threshold (“Z”). Microprocessor60 classifies the rhythm as one of a suspected non-lethal arrhythmia anda slow a suspected non-lethal arrhythmia based on this determination(214, 216). On the other hand, if either of minimum VCL (“X”) andsuspect (“Y”) thresholds is not met, microprocessor 60 determines thatthe rhythm is non-suspect, and proceeds to deliver a ventricular therapyscheduled for the detected arrhythmia (218).

As described above with reference to FIG. 7, RAM 62 stores the thresholdvalues, and in exemplary embodiments the minimum VCL threshold (“X”) isapproximately 270 milliseconds while the suspect threshold (“Y”) isequal to −30 milliseconds. Further, in exemplary embodiments, the slowsuspected non-lethal arrhythmia threshold (“Z”) is approximately 370milliseconds. Moreover, as described above, in some embodiments IMD 10determines whether the rhythm is a suspected non-lethal arrhythmia bydetermining whether the rhythm is a monomorphic VT instead of or inaddition to determining that a ventricular arrhythmia is a suspectedSVT. Threshold values for monomorphic VT classification can be the sameas an SVT threshold values, e.g., 270 and 370 milliseconds, or can beslightly longer, e.g., 300 and 400 milliseconds.

Various embodiments of the invention have been described. However, oneskilled in the art will appreciate that various modifications can bemade to the described embodiments without departing from the scope ofthe invention. For example, although described herein as applied todetection and treatment of ventricular arrhythmias, the therapy delayingand changing techniques of the invention can be additionally oralternatively applied by IMDs when detecting and treating atrialarrhythmias. These and other embodiments are within the scope of thefollowing claims.

1. A method comprising: measuring ventricular cycle lengths within aventricular rhythm; determining that a number of intervals to detect(NID) threshold for a ventricular arrhythmia is met based on themeasured ventricular cycle lengths; determining that the ventricularrhythm is a suspected non-lethal arrhythmia subsequent to thedetermination that the NID threshold is met; increasing the NIDthreshold based on the determination that the rhythm is a suspectednon-lethal arrhythmia; and measuring subsequent ventricular cyclelengths to determine whether the increased NID threshold is met.
 2. Themethod of claim 1, wherein the ventricular arrhythmia comprises one ofventricular fibrillation, ventricular tachycardia, and fast ventriculartachycardia, and the NID threshold comprises one of a ventricularfibrillation NID threshold, a ventricular tachycardia NID threshold, afast ventricular tachycardia NID threshold, and a combined count NIDthreshold.
 3. The method of claim 1, wherein determining that theventricular rhythm is a suspected non-lethal arrhythmia comprisesdetermining that the ventricular rhythm is one of a suspectedsupraventricular tachycardia and a monomorphic ventricular tachycardia.4. The method of claim 1, wherein determining that the ventricularrhythm is a suspected non-lethal arrhythmia comprises: comparing aventricular cycle length to an atrial cycle length, wherein theventricular cycle length is one of a median and a mean cycle length andthe atrial cycle length is one of a median and a mean cycle length; anddetermining that the ventricular rhythm is a suspected non-lethalarrhythmia based on the comparison.
 5. The method of claim 4, whereindetermining that the ventricular rhythm is a suspected non-lethalarrhythmia comprises determining that ventricular cycle length isgreater than or substantially equal to the atrial cycle length.
 6. Themethod of claim 5, wherein determining that the ventricular cycle lengthis greater than or substantially equal to the atrial cycle lengthcomprises comparing a difference between the ventricular cycle lengthand the atrial cycle length to a suspect threshold value.
 7. The methodof claim 4, wherein increasing the NID threshold comprises selecting anamount for the increase of the NID threshold based on the comparison ofthe ventricular cycle length and the atrial cycle length.
 8. The methodof claim 1, wherein increasing the NID threshold comprises selecting anamount for the increase of the NID threshold based on one of a medianventricular cycle length and a mean ventricular cycle length.
 9. Themethod of claim 1, wherein determining that the ventricular rhythm is asuspected non-lethal arrhythmia comprises determining that a ventricularcycle length exceeds a minimum ventricular cycle length threshold, andthe ventricular cycle length is one of a median and a mean ventricularcycle length.
 10. The method of claim 1, wherein determining that theventricular rhythm is a suspected non-lethal arrhythmia comprisesanalyzing at least one of regularity of the ventricular cycle lengths,regularity of a morphological feature of the ventricular rhythm, A:Vassociation, and rate of onset of at least one of atrial cycle lengths,ventricular cycle lengths, and A-V interval lengths.
 11. The method ofclaim 1, wherein determining that the ventricular rhythm is a suspectednon-lethal arrhythmia comprises analyzing one of an intracardiacpressure, respiration, and an activity level of a patient.
 12. Themethod of claim 1, wherein increasing the NID threshold comprisesincreasing the NID threshold to a first value, the method furthercomprising: determining that the ventricular rhythm is a slow suspectednon-lethal arrhythmia; and increasing the NID threshold to a secondvalue based on the determination.
 13. The method of claim 12, whereindetermining that the ventricular rhythm is a slow suspected non-lethalarrhythmia comprises determining that one of a median ventricular cyclelength and a mean ventricular cycle length is greater than or equal to athreshold value.
 14. The method of claim 1, wherein determining that theventricular rhythm is a suspected non-lethal arrhythmia comprisesidentifying at least one of cardiac and non-cardiac oversensing.
 15. Themethod of claim 14, wherein identifying at least one of cardiac andnon-cardiac oversensing comprises determining that one of a medianventricular cycle length and a mean ventricular cycle length is lessthan or equal to an oversensing threshold value.
 16. The method of claim1, further comprising: determining that the increased NID threshold ismet; and delivering a therapy to ventricles of a heart in response tothe determination.
 17. The method of claim 16, further comprisingchanging a scheduled therapy for the arrhythmia in response to thedetermination that the ventricular rhythm is a suspected non-lethalarrhythmia, wherein delivering a therapy in response to thedetermination that the increased NID threshold is met comprisesdelivering the changed scheduled therapy to the ventricles.
 18. Themethod of claim 17, wherein changing a scheduled therapy for thearrhythmia in response to the determination that the ventricular rhythmis a suspected non-lethal arrhythmia comprises applying a first changeto the scheduled therapy, the method further comprising: determiningthat the ventricular rhythm is a slow suspected non-lethal arrhythmia;and applying a second change to the scheduled therapy based on thedetermination.
 19. The method of claim 18, wherein applying a secondchange comprises applying the second change instead of the first change.20. The method of claim 1, further comprising: determining that theincreased NID threshold is met; determining that the ventricular rhythmis a suspected non-lethal arrhythmia subsequent to determining that theincreased NID threshold is met; and further increasing the NID thresholdbased on the determination that the rhythm is a suspected non-lethalarrhythmia
 21. The method of claim 20, wherein increasing the NIDthreshold comprises increasing the NID threshold by a first amount inresponse to a first determination that the ventricular rhythm is asuspected non-lethal arrhythmia, and further increasing the NIDthreshold comprises increasing the NID threshold by a second amount inresponse to a second determination that the ventricular rhythm is asuspected non-lethal arrhythmia.
 22. The method of claim 1, furthercomprising: determining that the increased NID threshold is not met; andresetting the NID threshold to a pre-increase value.
 23. The method ofclaim 1, wherein a clinician programs an initial and increased value forthe NID threshold.
 24. An implantable medical device comprising:electrodes to detect depolarizations of ventricles of a heart; a memoryto store a number of intervals to detect (NID) threshold for aventricular arrhythmia; and a processor to measure ventricular cyclelengths within a ventricular rhythm based on the detected ventriculardepolarizations, determine that the NID threshold is met based on themeasured ventricular cycle lengths, determine that the ventricularrhythm is a suspected non-lethal arrhythmia subsequent to thedetermination that the NID threshold is met, increase the NID thresholdbased on the determination that the rhythm is a suspected non-lethalarrhythmia, and measure subsequent ventricular cycle lengths based ondetected ventricular depolarizations to determine whether the increasedNID threshold is met.
 25. The device of claim 24, wherein theventricular arrhythmia comprises one of ventricular fibrillation,ventricular tachycardia, and fast ventricular tachycardia, and the NIDthreshold comprises one of a ventricular fibrillation NID threshold, aventricular tachycardia NID threshold, a fast ventricular tachycardiaNID threshold, and a combined count NID threshold.
 26. The device ofclaim 24, wherein the processor determines that the ventricular rhythmis a suspected non-lethal arrhythmia by determining that the ventricularrhythm is one of a suspected supraventricular tachycardia and amonomorphic ventricular tachycardia.
 27. The device of claim 24, whereinthe processor determines that the ventricular rhythm is a suspectednon-lethal arrhythmia by comparing a ventricular cycle length to anatrial cycle length and determining that the ventricular rhythm is asuspected non-lethal arrhythmia based on the comparison, and theventricular and atrial cycle lengths are one of median and mean cyclelengths.
 28. The device of claim 27, wherein the processor determinesthat ventricular cycle length is greater than or substantially equal tothe atrial cycle length.
 29. The device of claim 28, wherein the memorystores a suspect threshold value, and the processor determines that theventricular cycle length is greater than or substantially equal to theventricular cycle length by comparing a difference between theventricular cycle length and the atrial cycle length to the thresholdvalue.
 30. The device of claim 27, wherein the processor selects anamount for the increase of the NID threshold based on the comparison ofthe ventricular cycle length and the atrial cycle length.
 31. The deviceof claim 27, wherein the processor selects an amount for the increase ofthe NID threshold based on one of a median ventricular cycle length anda mean ventricular cycle length.
 32. The device of claim 24, wherein thememory stores minimum ventricular cycle length threshold, wherein theprocessor determines that a ventricular cycle length exceeds the minimumventricular cycle length threshold, determines that the rhythm is asuspected non-lethal arrhythmia based on the determination that theventricular cycle length exceeds a minimum ventricular cycle lengththreshold, and wherein the ventricular cycle length is one of a medianand a mean ventricular cycle length.
 33. The device of claim 24, whereinthe processor analyzes at least one of the regularity of the ventricularcycle lengths, regularity of a morphological feature of the ventricularrhythm, A:V association, and rate of onset of at least one of atrialcycle lengths, ventricular cycle lengths, and A-V interval lengths, anddetermines that the ventricular rhythm is a suspected non-lethalarrhythmia based on the analysis.
 34. The device of claim 24, furthercomprising a pressure sensor implanted within the to detect anintracardiac pressure, wherein the processor analyzes the intracardiacpressure and determines that the ventricular rhythm is a suspectednon-lethal arrhythmia based on the analysis.
 35. The device of claim 24,further comprising a circuit to measure an intrathoracic impedance of apatient via the electrodes, wherein the processor analyzes theintrathoracic impedance and determines that the ventricular rhythm is asuspected non-lethal arrhythmia based on the analysis.
 36. The device ofclaim 24, further comprising an activity sensor to detect activity of apatient wherein the processor analyzes the patient activity anddetermines that the ventricular rhythm is a suspected non-lethalarrhythmia based on the analysis.
 37. The device of claim 24, whereinthe processor increases the NID threshold to a first value based on thedetermination that the rhythm is a suspected non-lethal arrhythmia,determines that the ventricular rhythm is a slow suspected non-lethalarrhythmia, and increases the NID threshold to a second value based onthe determination.
 38. The device of claim 37, wherein the processordetermines that the ventricular rhythm is a slow suspected non-lethalarrhythmia based on a determination that one of a median ventricularcycle length and a mean ventricular cycle length is greater than orequal to a threshold value.
 39. The device of claim 24, wherein theprocessor determines that the ventricular rhythm is a suspectednon-lethal arrhythmia by identifying at least one of cardiac andnon-cardiac oversensing.
 40. The device of claim 39, wherein the memorystores an oversensing threshold value, and the processor identifies atleast one of cardiac and non-cardiac oversensing by determining that oneof a median ventricular cycle length and a mean ventricular cycle lengthis less than or equal to the oversensing threshold value.
 41. The deviceof claim 24, wherein the processor determines that the increased NIDthreshold is met and controls delivery of a therapy to the ventricles inresponse to the determination.
 42. The device of claim 41, wherein thememory stores a scheduled therapy for the arrhythmia, and the processorchanges the scheduled therapy in response to the determination that theventricular rhythm is a suspected non-lethal arrhythmia and controlsdelivery of the changed scheduled therapy to the ventricles in responseto the determination that the increased NID threshold is met.
 43. Thedevice of claim 42, wherein the processor changes the scheduled therapyin response to the determination that the ventricular rhythm is asuspected non-lethal arrhythmia by applying a first change to thescheduled therapy, determines that the ventricular rhythm is a slowsuspected non-lethal arrhythmia, and applies a second change to thescheduled therapy based on the determination.
 44. The device of claim43, wherein the processor applies the second change instead of the firstchange.
 45. The device of claim 24, wherein the processor determinesthat the increased NID threshold is met, determines that the ventricularrhythm is a suspected non-lethal arrhythmia subsequent to determiningthat the increased NID threshold is met, and further increases the NIDthreshold based on the determination that the rhythm is a suspectednon-lethal arrhythmia.
 46. The device of claim 45, wherein the processorincreases the NID threshold by a first amount in response to a firstdetermination that the ventricular rhythm is a suspected non-lethalarrhythmia, and increases the NID threshold by a second amount inresponse to a second determination that the ventricular rhythm is asuspected non-lethal arrhythmia.
 47. The device of claim 24, wherein theprocessor determines that the increased NID threshold is not met, andresets the NID threshold to a pre-increase value.
 48. The device ofclaim 24, wherein a clinician programs an initial and increased valuefor the NID threshold.
 49. The device of claim 24, wherein the device isimplantable within a patient.
 50. The device of claim 24, wherein thedevice comprises one of a pacemaker and apacemaker-cardiovertor-defibrillator.
 51. An implantable medical devicecomprising: means for detecting depolarizations of ventricles of aheart; means for measuring ventricular cycle lengths within aventricular rhythm based on detected ventricular depolarizations; meansfor determining that the NID threshold is met based on the measuredventricular cycle lengths; means for determining that the ventricularrhythm is a suspected non-lethal arrhythmia subsequent to thedetermination that the NID threshold is met; means for increasing theNID threshold based on the determination that the rhythm is a suspectednon-lethal arrhythmia; and means for measuring subsequent ventricularcycle lengths based on detected ventricular depolarizations to determinewhether the increased NID threshold is met.
 52. The device of claim 51,wherein means for determining that the ventricular rhythm is a suspectednon-lethal arrhythmia subsequent to the determination that the NIDthreshold is met comprises at least one of means for determining thatthe ventricular rhythm is a suspected supraventricular tachycardia andmeans for determining that the ventricular rhythm is a monomorphicventricular tachycardia.
 53. The device of claim 51, wherein means fordetermining that the ventricular rhythm is a suspected non-lethalarrhythmia comprises means for comparing a ventricular cycle length toan atrial cycle length, and the ventricular and atrial cycle lengths areone of median and mean cycle lengths.
 54. The device of claim 51,wherein means for determining that the ventricular rhythm is a suspectednon-lethal arrhythmia comprises means for analyzing at least one ofregularity of the ventricular cycle lengths, regularity of amorphological feature of the ventricular rhythm, A:V association, andrate of onset of at least one of atrial cycle lengths, ventricular cyclelengths, and A-V interval lengths.
 55. The device of claim 51, furthercomprising means for detecting an intracardiac pressure, wherein meansfor determining that the ventricular rhythm is a suspected non-lethalarrhythmia comprises means for analyzing the intracardiac pressure anddetermining that the ventricular rhythm is a suspected non-lethalarrhythmia based on the analysis.
 56. The device of claim 51, furthercomprising means for measuring an intrathoracic impedance of a patient,wherein means for determining that the ventricular rhythm is a suspectednon-lethal arrhythmia comprises means for analyzing the intrathoracicimpedance and determining that the ventricular rhythm is a suspectednon-lethal arrhythmia based on the analysis.
 57. The device of claim 51,further comprising means for detecting activity of a patient, whereinmeans for determining that the ventricular rhythm is a suspectednon-lethal arrhythmia comprises means for analyzing the patient activityand determining that the ventricular rhythm is a suspected non-lethalarrhythmia based on the analysis.
 58. The device of claim 51, furthercomprising means for determining that the ventricular rhythm is a slowsuspected non-lethal arrhythmia, wherein means for increasing the NIDthreshold comprises means for increasing the NID threshold by a firstamount for suspected non-lethal arrhythmias and a second amount for slowsuspected non-lethal arrhythmias.
 59. The device of claim 51, whereinmeans for determining that the ventricular rhythm is a suspectednon-lethal arrhythmia comprises means for identifying at least one ofcardiac and non-cardiac oversensing.
 60. The device of claim 59, whereinmeans for identifying at least one of cardiac and non-cardiacoversensing comprises means for determining that one of a medianventricular cycle length and a mean ventricular cycle length is lessthan or equal to a oversensing threshold value.
 61. The device of claim51, further comprising: means for determining that the increased NIDthreshold is met; and means for delivering a therapy to the ventriclesin response to the determination.
 62. A method comprising: measuringventricular cycle lengths within a ventricular rhythm; determining thata number of intervals to detect (NID) threshold for a ventriculararrhythmia is met based on the measured ventricular cycle lengths;determining that the ventricular rhythm is a suspected non-lethalarrhythmia subsequent to the determination that the NID threshold ismet; and changing a ventricular therapy scheduled for the arrhythmiabased on the determination that the rhythm is a suspected non-lethalarrhythmia.
 63. The method of claim 62, wherein determining that theventricular rhythm is a suspected non-lethal arrhythmia comprisesdetermining that the ventricular rhythm is one of a suspectedsupraventricular tachycardia and a monomorphic ventricular tachycardia.64. The method of claim 62, wherein determining that the ventricularrhythm is a suspected non-lethal arrhythmia comprises: comparing aventricular cycle length to an atrial cycle length, wherein theventricular and atrial cycle lengths are one of median and mean cyclelengths; and determining that the ventricular rhythm is a suspectednon-lethal arrhythmia based on the comparison.
 65. The method of claim62, wherein determining that the ventricular rhythm is a suspectednon-lethal arrhythmia comprises determining that a ventricular cyclelength exceeds a minimum ventricular cycle length threshold, and theventricular cycle length is one of a median and a mean ventricular cyclelength.
 66. The method of claim 62, wherein determining that theventricular rhythm is a suspected non-lethal arrhythmia comprisesanalyzing at least one of regularity of the ventricular cycle lengths,regularity of a morphological feature of the ventricular rhythm, A:Vassociation, and rate of onset of at least one of atrial cycle lengths,ventricular cycle lengths, and A-V interval lengths.
 67. The method ofclaim 62, wherein determining that the ventricular rhythm is a suspectednon-lethal arrhythmia comprises analyzing one of an intracardiacpressure, respiration, and an activity level of a patient.
 68. Themethod of claim 62, wherein the scheduled therapy comprises one of asequence of defibrillation shocks and a sequence of cardioversionshocks, and changing the scheduled therapy comprises one of reducing anumber of shocks in the sequence and replacing at least one of theshocks of the sequence with at least one anti-tachycardia pacingattempt.
 69. The method of claim 62, wherein the scheduled therapycomprises a sequence of anti-tachycardia pacing attempts, and changingthe scheduled therapy comprises one of canceling the anti-tachycardiapacing attempts, reducing a number of the anti-tachycardia pacingattempts, and increasing the number of the anti-tachycardia pacingattempts.
 70. The method of claim 62, wherein changing a scheduledtherapy for the arrhythmia in response to the determination that theventricular rhythm is a suspected non-lethal arrhythmia comprisesapplying a first change to the scheduled therapy, the method furthercomprising: determining that the ventricular rhythm is a slow suspectednon-lethal arrhythmia; and applying a second change to the scheduledtherapy based on the determination.
 71. The method of claim 70, whereinapplying a second change comprises applying the second change instead ofthe first change.
 72. The method of claim 70, wherein applying a secondchange comprises canceling the scheduled therapy.
 73. The method ofclaim 62, wherein determining that the ventricular rhythm is a suspectednon-lethal arrhythmia comprises identifying at least one of cardiac andnon-cardiac oversensing.
 74. The method of claim 73, wherein identifyingat least one of cardiac and non-cardiac oversensing comprisesdetermining that one of a median ventricular cycle length and a meanventricular cycle length is less than or equal to an oversensingthreshold value.
 75. The method of claim 62, further comprisingdelivering the changed scheduled therapy to ventricles of a heart. 76.The method of claim 62, further comprising: increasing the NID thresholdbased on the determination that the rhythm is a suspected non-lethalarrhythmia; and measuring subsequent ventricular cycle lengths; anddetermining that the increased NID threshold is met, wherein deliveringthe changed scheduled therapy comprises delivering the changed scheduledtherapy to the ventricles upon determining that the increased NIDthreshold is met.
 77. The method of claim 62, further comprisingdelivering anti-tachycardia pacing therapy to atria of a heart based onthe determination that the rhythm is a suspected non-lethal arrhythmia.